Manual De Psicofarmacologia Clinica Pdf Download
Sandrine Willert
IDoutorado em Psicologia - (professora de ps graduao do Instituto de Psicologia de Controle do Stress - IPCS)
IIDoutorado em Medicina - (Prof. Unicamp)
IIIPhD e ps-doutorado - (diretora do IPCS) - So Paulo - SP - Brasil
Maria, aged 35, began psychological treatment after referral by her psychiatrist, presenting severe obsessive-compulsive symptoms [OCs] which had a significantly adverse impact on her social and occupational function and on her health. Her obsessions were associated with the idea of infection and illness and her compulsions were cleanliness and hygiene. She also presented avoidance behaviors associated with these obsessions and deficit in social skills. Maria's life history and her psychological assessment enabled us to understand the development of her symptoms and to identify the predisposing, precipitating and maintaining aspects of the obsessive-compulsive disorder [OCD]. Based on the records kept during the cognitive-behavioral treatment, a reduction in the frequency of her compulsive behavior was observed. The client's self-assessment and the clinical observations also pointed towards improvement in social function and physical condition. Future efforts should include a follow-up to check for the maintenance of these gains.
Maria, 35 anos, iniciou tratamento psicolgico por indicao de seu mdico psiquiatra e apresentava sintomas obsessivo-compulsivos [OCs] severos, com significativo prejuzo no seu funcionamento social, ocupacional e na sua sade. Suas obsesses eram associadas ideia de contaminao e doena, e suas compulses eram de limpeza e higiene. Apresentava tambm comportamentos de esquiva associados s obsesses e reduzido repertrio social. A histria de vida e a avaliao psicolgica de Maria permitiram compreender a evoluo de seu quadro sintomatolgico e a identificao dos aspectos predisponentes, precipitadores e mantenedores do transtorno obsessivo-compulsivo [TOC]. Baseado no registro realizado durante os atendimentos psicolgicos, com o tratamento cognitivo-comportamental, observou-se uma reduo na frequncia dos comportamentos compulsivos. A auto avaliao da cliente e a observao clnica tambm apontaram uma melhora no funcionamento social e em sua condio fsica. No entanto, no foi possvel realizar o follow-up para averiguar permanncia dos ganhos obtidos durante o tratamento.
There were four main reasons that determined the choice of Maria's case for this study: the OCD diagnosis, the severity of the OC symptoms, the lack of prior psychological treatment, and the cognitive-behavioral treatment carried out. This case illustrates the incapacitation caused by OC symptoms and the influence of life history on the development and permanence of the disorder. An analysis of the records kept during the psychological therapy session also allowed us to ascertain the progress made with the cognitive-behavioral treatment.
The case progress was examined based on the frequency of compulsive behaviors recorded during the intervention process. During the first stage of intervention, records were made of the frequency with which the client would clean the house, as well as the frequency with which she washed her hands. In the second stage, a record was made of the quantity of cleaning and hygiene products purchased on a monthly basis and the bills for water consumption. The client's self-reports were also taken into account in respect of her progress and the clinical observations made by the therapist. As neither a final assessment nor a follow-up took place, it was not possible to make a comparison of the results obtained in the tests applied at the time of the initial assessment.
Maria first sought psychiatric help with the encouragement of her husband and mother. She went to the psychiatrist by way of referral by family members and used her health insurance plan to finance the treatment. She began drug treatment using 20 ml of Paroxetine, an antidepressant that inhibits serotonin reuptake. She was referred for psychological care by her psychiatrist and was assisted by the company where her husband worked in order to finance the expense of psychological treatment. The psychotherapy sessions were carried out in the same clinic in which the sessions with the psychiatrist were carried out.
The records made during Maria's psychological sessions were used as a source of data for the case study. These records contained the client's life history, her initial assessment, the interventions carried out and the development of her clinical picture over the course of the treatment.
Maria was 35 years old and married, and had been educated to high school level. She was born in a small town in upstate Sao Paulo, where she still lived. She had no children, did not work, and lived with her husband to whom she had been married for six years. She had an only brother, aged 23, who was single and lived with his parents. At the time when she started her psychotherapy, she presented with serious symptoms associated with OCD with a significant effect on her social and occupational function and on her health.
According to the classification by the American Psychiatric Association [APA] (2002), OCD belongs to the group of anxiety disorders, alongside phobias (specific, social and agoraphobia), generalized anxiety, panic and post-traumatic stress. The DSM V (2013) changed this and OCD was classified as obsessive-compulsive related disorder. Its fundamental feature is the existence of recurring obsessions and/or compulsions that consume time and foment significant harm in a variety of contexts (social, professional, family, and affective) of the life of the sufferer.
The obsessions correspond to urges, thoughts, impulses or persistent images which are experienced as intrusive and inappropriate and cause accentuated anxiety and suffering (APA, 2013). They materialize in a person's mind in a repetitive and stereotypical way, even though the person may recognize them as being unnecessary and absurd (Abreu, Cangelli Filho, & Cords, 2006). As for compulsion, this relates to repetitive behavior (e.g., washing the hands) whose objective is to prevent or reduce anxiety or suffering They are the behavioral counterpart to the obsessions and manifest themselves as an extreme need to act in accordance with a series of repetitive actions in order to avoid or prevent the threats contained in the obsessions (Abreu et al., 2006). Compulsions may present themselves in a number of ways such as the excessive washing of hands or objects, excessive checking of things (doors, windows, gas, etc.), a perfectionist attitude (the task of making each detail in a project absolutely perfect), praying, counting or repeating numbers and words in silence, amongst others (Abre et al., 2006).
OCD is considered to be quite a common illness. According to the review of literature conducted by Torres and Lima (2005), it is estimated that, amongst adults, OCD is currently prevalent in around 1% and, over the life span, between 2% and 2.5%, in the most diverse parts of the world. The review also indicated that, while epidemiological studies point to its predominant occurrence in women and to cases of pure obsession, clinical samples have evidenced a similar number of men and women and the majority of cases present with obsessions linked to compulsions which, according to the authors, suggests that the purely obsessive clients of the female sex may be turning less to the help of the health services.
OCD generally presents with a chronic clinical condition, with some fluctuations in severity. According to Cordioli (2008), there are several reasons that make OCD a serious mental disorder, including its early onset (generally at the end of adolescence and sometimes even in childhood), the level of incapacitation and the fact that it rarely exhibits complete remission of the symptoms. Individuals with OCD have many fears. They are superstitious, perfectionists, plodders and get embarrassed about carrying out rituals, all characteristics that provoke constant squabbles and social isolation (Niederauer, Braga, Souza, Meyer, & Cordioli, 2007). In addition to the devastating consequences which the disorder brings to the life of the sufferer, OCD also usually interferes with family life. The family is often obliged to accommodate itself to the symptoms, by altering their routines and having restrictions as to the use of spaces and objects. The expression "Family Accommodation" (Calvocoressi et al., 1995; Ferro & Floro, 2010) has been given to this phenomenon.
The seriousness of the OCD is also related to the sufferer's capacity for insight into their own OC symptoms. By insight, we mean the ability that a person has to critically evaluate their own mental state, including self-awareness and the acceptance of the existence of a morbid condition and the need for treatment (Fontenelle et al., 2010). The expression "with a high level of insight" is used for those suffering with OCD who demonstrate a good critical level concerning their state, while those having "little or no insight" have a partial or total inability to recognize the irrationality of their symptoms and the need for treatment. It is clear that the greater the client's ability for insight, the better their prognosis.
In a survey carried out by the World Health Organization [WHO] (1998), OCD was considered to be the fourth most common psychiatric disorder, surpassed only by depression, social phobia and substance abuse. It was also included by the WHO (1998) in the list of the ten illnesses (out of all the specialties) having the biggest impact on social incapacitation. The review of literature on the quality of life [QL] of OCD sufferers, conducted by Niederauer et al. (2007), suggested that the risk to the QL of these individuals is evident, to the point of being on a par with clients with schizophrenia, which is regarded as the most debilitating mental illness of all. According to the authors, the areas most affected by this disorder are social and family relationships, followed by occupational performance (ability to work and study), and obsessions were associated with more significant damage to the QL in comparison with compulsions (rituals). In another review of the literature on the same topic, population studies demonstrated indirect results of risk to QL in people with OCD, such as greater levels of unemployment, lower incomes and a lower rate of stable marital union, as well as relatively high rates of ideation and attempts at suicide. As for the clinical studies, these found higher risk to QL with OCD when compared to some chronic clinical illnesses, other anxiety disorders, depressive conditions, and even schizophrenia, in a number of aspects (Torresan, Smaira, Ramos-Cerqueira, & Torres, 2008).
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